5/30/2012 1 2 1 2 3 4 5 1 2 Hot Topics In Infection Control 4 Hours CE By Nancy Andrews, RDH,BS What’s So Hot??? • Basic tenants of IC • Bloodborne diseases • Hand hygiene • Skin issues • PPE • Re-usables vs. Single-use items • Sterilization • Biofilms • Environmental asepsis Dentistry Is A Fun Ride! • Sometimes we don’t see what’s coming • Sometimes things change • Sometimes things happen • Goodies, handout, action items, ?’s Safety Update • Written plan: where? Go over it! • Right to know: hazards • Exposed activities, who is exposed – To body fluids & injury • Know how pathogens are transmitted – Standard precautions • Safe practices • PPE • Safety devices • Vaccinations • PEP & emergency responses • Labeling & recordkeeping Who Is Included In IC rules? DHCP = All paid & non-paid workers who MAY be exposed to: • Infectious materials, fluids, supplies, surfaces, water, air • Includes lab tech’s – (on & off site) • Students, trainees, admin., maintenance, volunteers! 6 7 8 Chain of Infection Breaking the Chain IC Steps, Sequences • Chain of Infection • Instrument processing – dirty to sterile • Room cleaning, disinfection – Chaos & contamination to disinfected & ready • Hand Hygiene – Wash to clean 1 5/30/2012 9 10 11 12 13 14 15 – Alcohol to disinfect Basic Tenants of IC • Understand how diseases are transmitted • Clean before disinfecting • Isolate & separate • Make items safe to use / re-use • Have a plan – Educate, enforce, update • • Standard Precautions • Proven effective for controlling – Bloodborne diseases – Contact diseases – Droplet diseases • Not effective for airborne diseases Bloodborne Diseases • Acute vs. chronic – Symptomatic / asymptomatic – Some infected people recover • Chronic: antibodies: ineffective – HBV: highly infective,  liver destruction (work restrictions) – HIV: variable infectivity,  CD4 cell destruction (work restrictions) – HCV: often asymptomatic, undiagnosed, no work restrictions • Hepatitis • General term: “liver inflammation” • Caused by: – Toxins – Drugs – Autoimmune diseases – Heavy alcohol use – Bacterial / viral infections Your Liver • Major liver functions: – Secretes bile into intestine – Metabolism of carbohydrates, fats, proteins, fat-soluble vitamins: A, D, E, K – Storage of carbohydrates & lipids – Synthesis of all major plasma proteins except immunoglobulins (albumin, coagulation proteins, transport proteins for hormones, vitamins) • Viral Hepatitis • Infection with > viruses that attack liver • Most common in U.S.: Hepatitis A, B, C • Hepatitis A – Fecal – oral: spread by food & water contaminated with feces – Lasts weeks to months, not chronic – Usually resolves spontaneously – Vaccine is available • Other types: hepatitis D, E, G, & Transfusion Transmitted Virus (TTV) Hepatitis B Virus (HBV) • Bloodborne pathogen 2 5/30/2012 16 17 18 19 20 21 • Transmitted by sex, IV drug use, sharps injury, birth (1 in 3 chance infection from occup. exp.) • Survives & virulent outside body – 7 days • Vaccine gives immunologic memory > 23 years – No boosters – retain immunological memory indefinitely, protects vs. clinical illness & chronic dis. – 95% seroconvert after vaccination • “Carrier” = chronically infected & infectious • Tx = antiviral drugs Rare Pt-to-Pt HBV Transmission Summary • Only known documented case of HBV transmission between 2 dental pts in U.S. • More undetected cases? • Hardy virus – can persist in blood on surfaces for 7 or more days: also present in absence of visible blood • Can be prevented with vaccination • No cases of dentist-to-pt HBV transmission since 1987 • Reinforces need for meticulous IC • Vaccinations = valuable for those > 40 years old Why Do we need to know immunity & infectivity? Hepatitis C (HCV) • Most common chronic bloodborne infection in U.S. • 2.7 – 3.9 million Americans have chronic HCV – 4 X more than either HBV or HIV • Most chronic HCV carriers are baby boomers – Born 1946 – 1964 – ~75% = unaware of infection Hepatitis C (HCV) • Most commonly spread by: – Blood contact (healthcare workers, family) – Sharing contaminated needles (drugs) – Tattoo needle sharing – Sex – Mother to newborn at birth – Blood transfusions, organ transplants before 1992 – Clotting factors before 1987 Hepatitis C (HCV) • Some people clear infection • 85% develop chronic HCV • Can result in chronic liver disease, cirrhosis, liver cancer, death • Some types of HCV can be cured • No vaccine HCV-related Gangrene → Chronic Hepatitis C (HCV) • Begins as inflammation (immune cells attack virus in liver) • Untreated, leads to fibrosis (scarring) • Extensive fibrosis = cirrhosis (liver shrinks, hardens) • Liver damage accelerated by ETOH, age, duration of infection, HIV, medications • May be asymptomatic 20 – 30 years 22 23 Chronic Hepatitis C (HCV) Pathology • Portal hypertension (high BP in vein to liver from GI tract) 3 5/30/2012 24 25 26 27 28 29 30 • Esophageal and gastric varices (stretched, weak blood vessels – can rupture, leak) • Ascites (fluid build-up in abdomen) • Encephalopathy (mental confusion from blood-toxin build-up) • Blood-clotting deficiencies • Mal-nutrition Hepatitis C (HCV) • “Compensated cirrhosis”: – Liver is functional – Few or no symptoms • “Decompensated cirrhosis” – Liver failure (end-stage) – Transplant = only tx • Liver cancer (hepatocellular carcinoma) – One of fastest growing cancers in U.S. – HCV & cirrhosis are highest risk for CA – Hepatitis C (HCV) Tests • Diagnostic tests to ID HCV • CBC (complete blood count) • Liver enzyme & liver function • Viral load tests (amount of blood HCV RNA) – indicate viral multiplication – Range: “undetectable” – hundreds of millions – Lower viral load = easier to treat • Ultrasound, CT, MRI Imaging - detects liver damage or tumors • Liver biopsy (amount of damage) Hepatitis C (HCV) • No vaccine • Antiviral drugs: – Eliminate virus or lower viral load – May reduce complications & progression HIV - AIDS • Every 5 sec. Someone = infected • Virus attacks CD4 cells, weakens & destroys immune system • Patient becomes susceptible to opportunistic infections • Early tx before CD4 cells drop saves 70% more lives HIV Transmission • Blood • Sex • Pregnancy • Birth • Breast milk • 1/ 300 chance of infection w/ needlestick • No documented DHCW occupational infections from patients Chronic HIV • Fewer pills in HAART “cocktail” Increases compliance – If < 95% compliance  resistant HIV – Costs $1500.00 / month (if treated) • HIV+ life expectancy = 24 years • New concern: aging with HIV HIV / AIDS • Delayed diagnosis - still a problem 4 5/30/2012 31 32 33 34 35 1 2 36 • 20% of infected = unaware of status • 33% - diagnosed 1 yr before AIDS: too late to save life, far too late to prevent spreading HIV • States w/ biggest epidemics: Florida, NY, Texas, Georgia, NJ • HIV tx cuts transmission to partners 96% Preventive Meds for High Risk people • Daily antiretroviral meds offer partial protection vs. HIV – Tested in gay men (San Francisco) – Now testing heterosexuals in Africa (one HIV+ partner) • Risk of abandoning safe behavior? HIV / AIDS - Current Strategies • Rapid HIV type 1 + 2 Test: OraQuick: – Mouth swab or blood test – 99% accurate, 20 min. result – For source person testing or gen. Screening – Pre-arrange with Occupational Health M. D. Arms Clasped Behind Things Happen Risk of Infection after Needlestick Source HBV ………………. HCV …………………. HIV ………………….. Risk 6.0-30.0% 1.8% 0.3% Prevent Injury, Bloodborne Pathogen Exposure • Safe use / handling of sharps – Careful removal of blades, needles – Avoid pointing blades, burs, needles towards body – Use sharps containers at use-site – Protected transport of sharps • Use resuscitation devices, not mouth-to-mouth 37 38 39 40 41 Sharps Safety Devices Sharps Management • Must investigate safety devices • Only recap needles using: – Scoop technique or: – Mechanical devices designed to • hold needle sheath • eliminate need for 2 handed capping • Do not bend, break needles • Dispose of all sharp items in puncture resistant containers Anything Wrong? One-handed Scoop Technique 42 43 Occupational Exposure to Infectious materials 5 5/30/2012 44 45 46 47 48 1 2 First aid for exposure • Skin: – Wash thoroughly – running water & antimicrobial soap – Avoid abrading skin – If no water, use approved antiseptic hand cleanser, wash when possible • Eye: – Thoroughly rinse using eye wash station • Mucous membrane – Thoroughly rinse using antimicrobial – Orally: antiseptic mouthwash Occupational Exposure to Infectious materials First aid for exposure • Perenteral – – Control excessive bleeding – With limited bleeding: “milk” wound to flush – Thoroughly wash wound & adjacent tissue – antimicrobial soap & running water ASAP – If no water: approved antiseptic skin cleanser • Airborne – – Prevent exposure with masks NIOSH approved N95 masks for known airborne diseases unless immune (measles, chicken pox) • Susceptible workers stay out of room Are You Set UP? After the Accident: • Investigate: • How did it happen? • Why did it happen? • How could it be prevented? • Are there other similar risks / vulnerabilities? • Get everyone’s input! OSHA Update: • Make sure HCV is considered w/ PEP • Counseling • Oraquick: Rapid HIV testing: • After exposure: Test 3-6 weeks, 3-6 months, 9 months • Be able to get HAART - 2 hours • Training, technology & precautions have decreased # of needlesticks 3 fold - in last decade Get Your Vaccines Everyone: Some: • HBV • Influenza • Measles • Mumps • Rubella (German Measles) • Varicella – Zoster • • • • • Tetanus Polio HAV Pneumonia Meningitis 6 5/30/2012 • HPV • WWW.CDC.gov: new adult vaccine recs. Action Items: • Immunizations recommended for susceptible HCW’s when hired • Immunization regimens that require boosters • Immunization & chemotherapeutic agents given only if exposed to infections Shoulder Shrugs • Keep both arms at sides • Shrug shoulders toward ears • Hold 3 sec • Roll & lower shoulders backwards • Keep elbows straight throughout exercise 49 50 51 • Infectious diseases – #3 cause of death in US today (#1 in world) • 80% of common infections (colds, flu, diarrhea) – spread by contact, air, water, food, fomites (environment!) Hand Hygiene & Skin Care Hand Hygiene • Hand hygiene is the single most important factor in transmission of disease • 88% of dis. Trans. Is by hand contact • ‘Resident’ skin flora is permanent (IN skin) • ‘Transient’ flora is temporary (ON skin) target for routine hand • Which germs are the hygiene? 52 53 Soap & Water (Tucson Study) • Can reduce disease transmission 50% • 95% say they wash hands after using public restroom • 67% actually do • 33% use soap • 16% wash long enough • 54 55 56 Handwashing: Frequently Missed Areas 57 58 59 60 1 2 Effective Handwashing • How long should you lather? • Do you rinse thoroughly? • Do you use lotions? • Do you always dry completely with disposable towel? • Do you have chapped, irritated skin? – Who only washes? – What soap do you use? – Most Recommended: Combined Protocol • Plain soap – routine handwashing • Antimicrobial / alcohol - main method on unsoiled hands 7 5/30/2012 61 62 63 64 65 66 67 Soap: Is It Effective? • Goal: physically remove debris, bioburden - reduce organisms • Active ingredients / formula - optimize: – Cleaning: surfactant – Fast action • Effective contact time aided by foam: instant lather, better coverage – Broad (& targeted) antimicrobial spectrum of activity – Persistence of antimicrobial activity? Soap Dispenser Contamination • Microbial contamination of soap linked to infections & outbreaks in hospitals • 25% of refillable containers had bacteria • 16% had coliforms • Some bacteria remains on hands after washing • No bacteria found in sealed (1 use) dispensers Soap Safety • Soaps can become contaminated. – No “topping off” soap dispensers – Buy Professional products: higher quality control • Professional standards are higher than home Waterless Hand-Rub Safety • Should have ethanol, not isopropyl alcohol – Less drying to skin – More effective vs. Viruses • Must have enough emollients for heavy clinical use Hands & Skin • Products should be designed to protect skin • Inflamed, irritated skin – has more bacteria, handwashing fails to remove – Doubles risk of infection • Flora multiplies under gloves rapidly: doubles every 12 min. Dermatitis Dermatitis • 30% of HCW’s • Mostly irritant contact dermatitis • Allergies are rare • Caused by – Detergents & water – Occlusive gloves (proteins, chemicals) • 68 69 70 71 72 Look Out! Skin Exposures • Non-intact skin may allow pathogens, irritants, allergens to enter • How? – percutaneous injury with contaminated objects – existing cuts / openings – dry, cracked skin Drug Resistance • Incidence linked to exposure, susceptibility & over-use of antibiotics • MRSA = resistant to methicillin, penicillin, amoxicillin, cephalosporins) • Dr.’s now use Clindamycin & Bactrim, Zyvox, incision / drainage 8 5/30/2012 73 74 75 76 77 78 79 80 • Vancomycin may cause thrombocytopenia, hearing & kidney damage • MRSA enters open skin. Pimples, boils, lesions; may lead to pneumonia, severe skin, bone, bloodstream infections, septic arthritis, endocarditis, deep abscesses, toxic shock Resistant skin infections…. What should you look for? MRSA Surgical Incision Infection Staph Infections (Tattoos) Staph Infections MRSA Cellulitis Staph MRSA MRSA Infection 81 82 83 84 85 86 • Transmitted on towels, clothes, surfaces, equipment, skin-to-skin contact • Enters broken skin • Causes HIGH FEVER • Often undiagnosed - allowed to progress • Tx may be IV AB’s, high $, side effects • Follow CDC Recommendations – they work! • Get a diagnosis!!!! • • How do you know what that sore, itchy, red, rough skin is? • Allergy? • Hypersensitivity? • Contact dermatitis? • Infection? – Bacterial? – Fungal? – Resistant? Prevent Injury, Skin Exposure • Safe use / handling of sharps • Hand hygiene • Safe practices – slow down! • Cover cuts, first aid • Even at home! • Must NOT treat pts or touch pt care items with weeping, exudative lesions or dermatitis Action Items Protect skin openings Watch for symptoms Clean environmental surfaces Common Mistakes (That harbor organisms & may damage gloves) • False nails, Nail polish & applications 9 5/30/2012 87 1 2 • Un-manicured nails • Jewelry • Petroleum-based products • Bar soap Keep It Balanced! • Plain soap – routine handwashing • Antimicrobial / alcohol - main method on unsoiled hands 88 89 90 Wrist Postures • Deviated wrist positions increase pressure in Carpal tunnel: – Flexion: two fold – Extension: four fold 91 92 93 94 95 96 Back, Hip Stretch Allergies • Latex • Accelerators in gloves • Disinfectants, cleaners (glutaraldehyde) • Preservatives – Cosmetics, skin care, shampoos, household & industrial products • Acrylates (adhesives, glues, bonding agents). Monomer can cause persistent finger paresthesia, nerve damage – Allergy Treatments • Skin prick testing • Patch testing (Type IV testing) • MD’s often treat without exact diag. • Misdiagnosis & use of creams, ointments to palliate symptoms – often inadequate, prolong condition • Steroid creams cause skin thinning • • Dermatitis – Vicious Circle • Alcohol rubs burn – Avoid, wash more (> water) • Washing hurts • Wash fast, rinse less, dry less • > soap residue • > chapping • Disturbed skin flora • > susceptible to skin pathogens Dermatitis – Break the Cycle: Heal • Effective cleaning, soap removal, drying • Emollients: – Lotion soap – Lotions – Barrier creams – Need enough (professional product) – Non-petroleum • Time……….. 97 10 5/30/2012 98 Airborne Diseases • Measles • Varicella (including disseminated zoster) ¥ • Tuberculosis ¥£ , Flu • • • • • • ¥ requires >1 precaution £ See CDC TB Guidelines 99 100 101 Influenza Signs & Symptoms • Fever – sudden onset – Babies: > 100.4 – Others: > 101.1 • Cough • Sore throat • Intense body aches • Headache • Chills • Fatigue • Some: diarrhea, vomiting H1N1: resistant to amantadine & rimantadine, and now…. partially to oseltamivir & zanamivir 102 103 104 105 106 Who Should Be Vaccinated? • Everyone over 6 months old (CDC) • Even those who had flu! – Confirmed previous cases: vaccine improves immunity – Suspected previous H1N1 cases: vaccinate • HIGHLY recommended if: – have existing health problems – have contact with children under 5 – healthcare professionals – Office & Home Asepsis • Wash hands when arrive & frequently • Clean highly touched spots – Doorknobs, handles, tables, phones, pens, car, kitchen, bathroom, remote controls, sinks, chairs • Don’t share pens, towels, cups, utensils • Sanitize / wash after touching money, public surfaces www.parenting.com Measles – Still Killing Kids • Leading cause of death in children (worldwide) • 10-12 day incubation • High fever (1 wk), runny nose, cough, white spots in mouth: precede rash Pertussis 107 11 5/30/2012 108 109 110 Aerosol Transmissible Diseases • Pathogens capable of surviving air suspension: – Suspension in air, desiccation – Travel on dust particles, air currents – Particles < 5u – Absorption through conjunctivae, mucosal tissue of nose, respiratory tract – Airborne Precautions • Private (-) pressure room • 6 – 12 air changes / hour • Safe discharge of air outdoors or monitored high efficiency filtration of room exhaust air • Keep door closed, pt. in room • N95 respirator to enter room – Unless immune to measles, varicella • No entry to susceptible HCW’s • Mask on pt. to transport • Best Practices (& Calif. Law) • No dental tx performed on pt’s with ATD (or suspected) • Written OSHA screening procedure for ATD’s (CDC screening) • Screening performed prior to tx • Employees trained to screen – Confirmation calls & @ check-in – Protect pt privacy, show concern! • Aerosol procedures only done with MD’s clearance - “pt non-infective” Get Started! • Train all employees • Inform patients: – Patients with ATD’s must be seen in special facilities only – Symptomatic patients will be dismissed • Ask patients to only come to office when healthy • Screen when: make appt, confirm, pt arrives – – • Ask patients to inform 111 112 113 114 Screening for ACTIVE Cases • Goals = reduce transmission by: – Early detection @ check-in – Prompt isolation – Implement respiratory hygiene / cough etiquette – Defer elective tx – Refer emergency / acute cases • For dental emergencies • For medical care – Implement appropriate precautions Active TB Mycobacterium tuberculosis • Mtb infection is NOT synomynous with ACTIVE TB! • Positive skin test does mean ACTIVE TB! 12 5/30/2012 • Vaccinated people have (+) skin tests, need chest X-rays to screen 115 Tuberculosis Policy • MDR TB = worldwide risk • Develop TB program appropriate to risk • Tuberculin skin test (TST) when hired & per risk • Ask all pts: – History of TB? – Symptoms of TB? Testing foreign-born vaccinated people: 116 117 • TB blood tests (interferon-gamma release assays or IGRAs), unlike the TB skin test are not affected by prior BCG vaccination • Symptom tests • ATD screening form • Chest X-ray? Rapid TB Test • MDR TB – growing concern world-wide • Xpert PCR 2 hr rapid test detects TB (90% accuracy) • Rifampin-resistant M. tuberculosis infection detected (97.6% accuracy) – more accurate than conventional phenotypic susceptibility testing • Cost = between culturing & sputum smear microscopy • Goal: reduce TB by early ID & tx Screen for TB: • Productive cough ( > 3 weeks) – Bloody sputum • Night sweats • Fatigue • Malaise • Fever • Unexplained weight loss • If yes: medical referral, (reportable) 118 119 120 1 2 Flu & Other ATD’s Ask: Do you have…. • Flu – Fever? – Body aches? – Runny nose? – Sore throat? – Headache? – Nausea? – Vomiting or diarrhea? • If yes, re-appoint, refer • • Pertussis, measles, mumps, rubella, chicken pox, meningitis – Fever, respiratory symptoms + – Severe coughing spasms – Painful, swollen glands – Skin rash, blisters – Stiff neck, mental changes 13 5/30/2012 121 122 123 124 125 126 127 128 129 Chronic Respiratory Diseases (NOT ATD’s) • Asthma • Allergies • Chronic upper airway cough syndrome “postnasal drip” • Gastroesophageal reflux disease (GERD) • Chronic obstructive pulmonary disease (COPD) • Emphysema • Bronchitis • Dry cough from ACE inhibitors Dental Worker Health • Symptomatic workers must be evaluated promptly • No work until: – MD rules out ATD or – Worker is on therapy & is noninfectious Post Signs • Cover your cough (lists symptoms patients should report to staff) • http://www.cdc.gov/ncidod/dhqp/pdf/Infdis/RespiratoryPoster.pdf • Cover your cough instructions and fliers in several languages • http://www.cdc.gov/flu/protect/covercough.htm Summary Stretch Back of Neck • Turn head away from tight side • Look down, feel stretch • Hold chair on tight side • Pull head forward with other hand • Repeat, looking up PPE Surgical Masks • Designed to protect patient from: – Oral, nasal, respiratory tract flora – (Breathing, speaking 1-3 cfu / min) • Masks are bi-directional barriers ASTM Levels Fluid Resistance • Masks saturated from both sides • “Wicking” • Mask degrades from; – Perspiration – Talking – Sneezing – Length of time mask is worn • 20 min. – 1 hr. Use-life • Shield may lengthen use-life • Position mask to “stand out” from face • 130 131 132 133 134 135 Formal Wear Female Heart Attack Symptoms 14 5/30/2012 136 137 138 139 140 • Nausea • May never have chest pain • Or: chest, arm, jaw pain • Intense jaw pain (unique) • Intense sweating • If asleep jaw pain may awaken • Or: 60% of those who have MI during sleep do not wake up Surviving Heart Attack Alone • The scene: Alone, sudden pain • Arrythmia, faint: 10 sec. consciousness • Surviving Heart Attack Alone • Cough deeply, vigorously, prolonged • Repeat ea. 2 seconds – Squeezes heart • Deep breath before each cough – Gets air to lungs, blood • Until help arrives • Or, heartbeat returns to normal • Get to hospital Operatory Asepsis Is this a problem? Does this ever happen? 141 142 143 144 145 146 147 148 149 Stretch Chest • Clasp hands behind head • Inhale slowly, bringing elbows back • Exhale slowly, bring elbows together, bend head forward Dental Office Surface Asepsis Microorganism Survival on sufaces • Respiratory viruses – hours – 3 days • Enteric viruses – days – weeks • Enteric bacteria – hours – 2,3 days • Staphylococcus aureus (MRSA) – days – weeks • Spores – weeks years Impact of Disinfectant Wipes on Absenteeism • Study: 3rd & 4th graders, 2 semesters • Wiped desks with disinfectant wipes, end of each school day • Results: 50% reduction in absenteeism Action Item: Your Cleaning Service 150 151 Dental Aerosols – Visible? 152 153 154 155 156 Single-use items IT’s Tempting… To Re-use Single-use items Cover or Remove Extra Items Load trays outside operatory 15 5/30/2012 157 Simplify Surfaces 158 Environmental disinfection = cardinal feature in dentistry Estimating Risks What is the most frightening disease you could catch in dentistry? 159 The scariest things might be the easiest to stop 160 Hierarchy of Resistance • Bacterial spores - Bacillus subtilis • Mycobacteria - Mycobacteruim tuberculosis (benchmark organism for intermediate level disinfectants) • Nonlipid or small viruses (Non enveloped) - Polio virus • Fungi - Trichophyton spp. • Vegetative bacteria - Pseudomonas aeruginosa, Staphylococcus aureus • Lipid or medium-sized viruses - Herpes simplex virus, hepatitis B virus, HIV CDC Chemical Disinfectants Intermedient Level Disinfectants Kill TB (benchmark): • Mycobacteria - Mycobacteruim tuberculosis • Nonlipid or small viruses (Non enveloped) - Polio virus • Fungi - Trichophyton spp. (Low level hospital disinfectants kill only): • Vegetative bacteria - Pseudomonas aeruginosa, Staphylococcus aureus • Lipid or medium-sized viruses - Herpes simplex virus, hepatitis B virus, HIV (CDC) Intermediate - Level Disinfectants For Clinical Contact Surfaces • Between patients: • Counter tops, dental unit surfaces • Intraoral items going to + coming from lab. – Bite registrations, restorations – Prosthetic, ortho. appliances Cleaning / Disinfection of Lab Cases Are You Cleaning Before Disinfecting??? Which products clean? Basic IC Rule: Clean Before Disinfection Which Products Clean & Disinfect? • High % Alcohol Solutions (Over 20%) • Damage surfaces, equipment • Desiccate: adhere (fix) bioburden to surfaces • Rapid evaporation: reduced contact time • Ineffective pre-cleaner – must use other product to clean first • Disinfectant only (step 2) *?* Do NOT use high alcohol product to both clean and disinfect! Clean Before Disinfecting Leave For Stated Time Prevent Contamination CDC Update • New technology: Items used intra-orally – Non-sterilizable, re-usable: use FDA cleared barrier & EPA intermediate level disinfectant 161 162 163 164 165 166 167 168 169 170 16 5/30/2012 • (digital sensors, caries diagnostic devices, intra-oral cameras – protective sheaths) • Aseptic technique • Big issues: – Compliance – Antibiotic resistance Digital Sensors Green IC ??? • Fewer / no toxins – Biodegradable surface disinfectants • Re-usable vs. Disposable items – Cloth sterilization pouches • Recyclable / recycled barriers, items – Is there available pick-up? – Know requirements for green processing / biodegrading (compost?) • Reliable IC? - Ask: Does it work?? Screening Practice Screen for TB: • Productive cough ( > 3 weeks) – Bloody sputum • Night sweats • Fatigue • Malaise • Fever • Unexplained weight loss • If yes: medical referral, (reportable) 171 172 173 174 175 1 2 176 Flu & Other ATD’s Ask: Do you have…. • Flu – Fever? – Body aches? – Runny nose? – Sore throat? – Headache? – Nausea? – Vomiting or diarrhea? • If yes, re-appoint, refer • • Pertussis, measles, mumps, rubella, chicken pox – Fever, respiratory symptoms + – Severe coughing spasms – Painful, swollen glands – Skin rash, blisters – Stiff neck, mental changes Dental IC Concerns • Many emerging, re-emerging dis’s present first with flu-like symptoms – Fever, respiratory problems, malaise – Patients may seek dental care – Reschedule! • Evaluate effectiveness of usual products & practices 17 5/30/2012 177 • Prepare alternatives Labeling and signs 178 179 What is this? 180 181 What’s going on here? 182 183 184 185 186 187 188 189 Instrument Processing Highest Level of Asepsis CDC Update • Must heat sterilize ALL removable handpieces, even slow speeds – *electric handpieces: housing / sleeves = sterilizable, but micromotors may not be! How Do You Transport? • Protect Sharps – Cassettes – Tubs, trays with slides, lids – Avoid accidents • Use Cassettes / tubs / lids –  Is This OK? OK? Minimize: Pre-Cleaning / Holding 190 191 192 Instrument Processing “Traffic Flow” 193 194 195 196 197 What’s Wrong? What’s Wrong? 198 199 200 201 202 203 Sterilizer Monitoring • Indicators: per package – Heat • Integrators: per load – Time, temperature, pressure • Biological Monitors: weekly – Non - pathogenic spores – Keep written reports 204 205 206 Biofilms WOW 207 208 Current Disease Concepts 18 5/30/2012 209 210 211 1 2 • Dis. = not invasion of single pathogen • Dis. Often results from collective “pathogenic agent” – metabolically inter-dependant bacteria • Gut bacterial communities affect weight gain (mice study) • Skin biota made up of resident unique species mix + transient (changing) bact. • Researchers seeking microbial signature for psoriasis & eczema Biofilm & Chronic, Resistant Infections • Last 15 yrs: medical community recognizes BF as distinct from planktonic bacteria • Acute bacterial infections (often non-BF) • Chronic infections (often BF- acting as a multi-cellular organism) • Antibiotics kill reproducing organisms • BF organisms slow down • • Inflammation • Understanding inflammation is key • Prostate research: – Men 55 – 60 years old: prostates heavily colonized with bacteria – If have specific inflammatory response, have prostatitis • Many middle ears colonized with biofilm bacteria – Inflm. determines infection • Understanding inflammatory modulation in ears & prostates: helps perio research • Health Care Associated Biofilm Infections • Hospital Pneumonia • Sutures, exit sites • Arteriovenous shunts • Contact lenses • Urinary catheter cystitis • Peritonitis • IUD’s • Endotracheal tubes • Catheters • Mechanical heart valves • Vascular grafts • Orthopedic devices • Penile prostheses • 0% success w. Anti-biotics alone (must remove) Science Vol 284 21 may 1999 212 213 Dental Water Quality 214 215 216 2 Standards for Water Safety • Sterile - for surgery, (cutting bone, normally sterile tissue) – 0 CFU/mL of heterotrophic water bacteria – CDC special update, OSAP, Dental Board law • Potable - for non- surgical procedures – 500 CFU/mL of heterotrophic water bacteria (meets EPA safe drinking water standards) – CDC, OSAP, EPA, Dental Board Self Contained Water Systems – For non-surgical procedures: < 500 CFU (potable) 19 5/30/2012 – Access to add chemicals – Treatment fluid: • Sterile water • Freshly distilled water • Medicaments / antimicrobials – Must treat regularly – Biofilm returns Waterline Treatment Options • Chemical “Shock” - removes biofilm – Sterilex, bleach – Caustic, may injure tissue. Rinse ! • Continuous chemical “maintenance” - prevents biofilm, keeps CFU’s low. – DentaPure 1 /year – BluTab (Silver ions) - ProEdge – ICX (Silver ions) – Adec – Team Vista - HuFriedy Treat ALL waterlines Do your waterlines retract? Handpieces, AWS, Ultrasonics If You Don’t Clean It • You can’t disinfect it • You can’t sterilize it 217 218 219 220 221 222 223 1 2 224 Seal-Tight Disposable Air / Water Syringe Tips How’s Your Office? - Hot??? • Basic tenants of IC • Bloodborne diseases • Hand hygiene • Skin issues • PPE • Re-usables vs. Single-use items • Sterilization • Biofilms • Environmental asepsis What You Do Over & Over 225 20